Dermatological aspects of cerebrovascular diseases

Neurological symptoms are sometimes triggered by the same mechanisms as are skin manifestations. They include genetic conditions like the epidermal nevus syndrome, the Sneddon syndrome, Fabry disease and others, as well as certain inflammatory disorders like erythematous lupus, Bechet disease. Basically all conditions giving rise to anticoagulation processes may cause simultaneously neurological and cutaneous manifestations. Cerebrovascular stroke is the third most common condition of death in the developed world after cancer and ischemic heart disease. The mechanisms responsible for development of skin manifestations in patients afflicted by stroke are shortly reviewed. Stroke may also influence the already existent skin diseases.     

Case-finding effectiveness of partner notification and cluster investigation for sexually transmitted diseases/HIV

OBJECTIVE: To assess the case-finding effectiveness of partner notification(PN) and cluster investigation for sexually transmitted disease (STD)/human immunodeficiency virus (HIV). STUDY: Literature review and quantitative summary. RESULTS: Since 1975, the median case-finding yield for syphilis, gonorrhea, and chlamydia PN reported in the literature is about 1 new case found for every 4 or 5 cases interviewed. The yield from HIV PN is approximately half as large, although there is substantial variability in yield across reports for each disease. Published reports underline the central role provider referral plays in effective PN and case-finding. Successful PN is more likely with index cases who are of majority ethnicity and detected through screening or spontaneous presentation for care with symptoms and with partners with whom index cases have had sexual contact that is recent, frequent, and of long duration. The case-finding yield for HIV PN also is much higher when cases are diagnosed through confidential, rather than anonymous, testing. Cluster investigation and related strategies tend to have lower case-finding yields than PN but can play a very useful case-finding role, especially in settings with high disease incidence. CONCLUSIONS: STD/HIV PN and cluster investigation can contribute meaningfully to case finding. More research is needed to strengthen the empiric foundation of PN and related strategies, including the impact they have on disease transmission.     

Dermatological manifestations of hematologic neoplasms. Part II: nonspecific skin lesions/paraneoplastic diseases

Cutaneous manifestations occur in the course of hematologic malignancies and precede, accompany or occur late in relation to the diagnosis. They result from paraneoplastic phenomena, tumor infiltrations, immunosuppression resulting from the hematologic disease itself or its treatment. The dermatologist must be aware of these conditions that may be helpful both in the diagnosis of the underlying disease and in reducing patient morbidity. This review (part II) addresses the paraneoplastic dermatological changes associated with systemic hematologic malignancies.     

Dermatological manifestations in Noonan syndrome

Noonan syndrome (NS) is a genetic disorder affecting up to 1 in 1000 people. It is recognised by an unusual facial appearance, heart defects and small stature. Some people with features of NS also have lots of small dark brown flecks on their skin (lentigines), a condition formerly known as LEOPARD syndrome but now called NS with multiple lentigines (NSML). There are also some atypical (unusual) “Noonan-like” syndromes: this overlapping group of “Rasopathies” also includes Costello syndrome and cardio-facio-cutaneous syndrome. About 10 genes responsible for these conditions are now known, but the dermatological (skin) features of the different genetic types have never been clearly defined. Therefore, these French doctors, based at 10 different hospitals, systematically recorded the skin abnormalities seen in patients with any kind of NS attending their clinics over a 4-year period, and correlated them with NS subtype and gene. Of 129 patients, aged from 9 months to 77 years, three quarters had mutations (changes) in the PTPN11 gene and of these 65 were diagnosed as NS and 34 as NSML. Dermatological features in the NS patients were mild and non-specific such as easy bruising, raised hair follicles (keratosis pilaris), lax skin or wavy hair. NSML patients additionally had dozens of lentigines, larger brown patches and usually had particular PTPN11 mutations. NS patients with mutations in a different gene were more likely to have striking skin features including unusually curly hair, sparse eyebrows, marked keratosis pilaris or multiple moles. This research highlights the value of careful dermatological documentation in patients with genetic syndromes.     

Dermatological legal claims in Japan

Health-care safety management has recently been highlighted for patient safety. However, specialist-based risks in clinical settings have hardly been discussed in Japan so far. A review of dermatological legal claims may delineate these risks. This study examined court precedents from the databases "Courts in Japan" and LEX/DB. Thirty-four dermatology-related civil cases were found from 1968-2006. Of the 34 cases, 32 (94%) were judged and two (6%) were retried. Of these 32 cases, 11 (34%) were appealed to higher courts. Among the 34 litigations, the defendants of eight (23%) were dermatology specialists, 20 (59%) were non-dermatologists and six (18%) of unknown specialty. The defendants' negligence was determined at either level in court in 25 of the 34 cases. The negligence in these 25 cases was categorized into five groups: (i) delayed diagnosis (none); (ii) complication during diagnosis procedure (one, 4%); (iii) inappropriate treatment (nine, 36%); (iv) complication during treatment procedure (10, 40%); and (v) insufficient informed consent (five, 20%). The present study may help to improve strategies for health-care safety management in the dermatological field in Japan.     

Dermatological aspects of angiogenesis

Neovascularization is vital for the growth of tumours, providing a lifeline for sustenance and waste disposal. Tumour vessels can grow by sprouting, intussusception or by incorporating bone marrow-derived endothelial precursor cells into growing vessels. Recent advances in vascular biology have identified some key factors that control vascular growth, and have led to the hypothesis that in normal tissues vascular quiescence is maintained by the dominant influence of endogenous angiogenesis inhibitors over angiogenic stimuli. In contrast, increased secretion of angiogenic factors and the down-regulation of endogenous angiogenesis inhibitors induce tumour angiogenesis. Vascular quiescence in the skin seems to be primarily maintained by a balance between the endogenous angiogenesis inhibitors thrombospondin 1 and thrombospondin 2 and the potent proangiogenic factor vascular endothelial growth factor A. Inhibiting tumour growth by controlling angiogenesis is an intriguing approach with great potential for the treatment of vascular tumours such as haemangioma, Kaposi's sarcoma and solid cutaneous tumours such as squamous cell carcinoma, melanoma and basal cell carcinoma. In this review, the role of angiogenesis and more recent topics such as lymphangiogenesis in cutaneous tumour growth, invasion and metastasis will be discussed.     

Dermatological complications of obesity

Obesity is a health problem of considerable magnitude in the Western world. Dermatological changes have been reported in patients with obesity, including: acanthosis nigricans and skin tags (due to insulin resistance); hyperandrogenism; striae due to over extension; stasis pigmentation due to peripheral vascular disease; lymphedema; pathologies associated with augmented folds; morphologic changes in the foot anatomy due to excess load; and complications that may arise from hospitalization. Acanthosis nigricans plaques can be managed by improved control of hyperinsulinemia; the vitamin D3 analog calcipitriol has also been shown to be effective. Skin tags can be removed by snipping with curved scissors, by cryotherapy or by electrodesiccation. Hyperandrogenism, a result of increased production of endogenous androgens due to increased volumes of adipose tissue (which synthesizes testosterone) and hyperinsulinemia (which increases the production of ovarian androgens) needs to be carefully assessed to ensure disorders such as virilizing tumors and congenital adrenal hyperplasia are treated appropriately. Treatment of hyperandrogenism should be centred on controlling insulin levels; weight loss, oral contraceptive and antiandrogenic therapies are also possible treatment options. The etiology of striae distensae, also known as stretch marks, is yet to be defined and treatment options are unsatisfactory at present; striae rubra and alba have been treated with a pulsed dye laser with marginal success. The relationship between obesity and varicose veins is controversial; symptoms are best prevented by the use of elastic stockings. Itching and inflammation associated with stasis pigmentation, the result of red blood cells escaping into the tissues, can be treated with corticosteroids. Lymphedema is associated with dilatation of tissue channels, reduced tissue oxygenation and provides a culture medium for bacterial growth. Lymphedema treatment is directed towards reducing the limb girth and weight, and the prevention of infection. Intertrigo is caused by friction between skin surfaces, combined with moisture and warmth, resulting in infection. This infection, most commonly candidiasis, is best treated with topical antifungal agents; systemic antifungal therapy may be required in some patients. Excess load on the feet can result in morphological changes that require careful diagnosis; insoles may offer some symptom relief while control of obesity is achieved. Obesity-related dermatoses associated with hospitalization, such as pressure ulcers, diminished wound healing, dermatoses secondary to respiratory conditions, and incontinence, must all be carefully managed with an emphasis on prevention where possible. Recognition and control of the dermatological complications of obesity play an important role in diminishing the morbidity of obesity.     

Dermatological survey of onchocerciasis in Guatemala

A comprehensive survey of onchocerciasis was performed on 1259 inhabitants in San Vicente Pacaya and the surrounding area. The total number of inhabitants examined was 1259, 763 males and 496 females. An examination of microfilarial density was carried out by the skin snip method. There were 610 microfilarial positives (50.4%) out of 1211 persons, 448 males (60.9%), and 162 females (34.1%). Nodules were examined by palpation, and there were 404 (32.8%) positives for nodule out of 1232 persons, 299 males (40.3%), and 105 females (21.4%). Eczematous dermatitis was seen in 149 persons, the generalized type in 13, and other types in 136. Depigmentation on the lower extremities was seen in 290 persons, the severity was graded from 0 to 4, and grade 1 depigmentation was seen in 91; grade 2, in 143; grade 3, in 52 and grade 4 in 4 persons out of 1159 individuals examined. The positives for lymphadenopathy (above grade 2) were 464 (41.2%) out of 1127 individuals. Itching was seen in 129 (18.3%) of 705 individuals examined by the inquiry card method. The correlation between skin changes and onchocerciasis was also analyzed. Those individuals who were microfilarial positive in the skin snip and eyes, and who had palpable nodules were defined as being onchocerciasis patients. There was a high frequency of eczematous dermatitis, depigmentation on the lower extremities and lymphadenopathy in the onchocerciasis infected group, compared with the non-infected group, but there was no difference in the rate of itching between them. Hanging groin, elephantiasis and "erisipela de la costa" were not seen in this endemic area, and the degree of skin changes was slight, compared with that reported in Africa thus far.